The stigma of mental illness, a commander's or a soldier's focus on their career, the worry about confidentiality -- all of these can prevent soldiers from getting the mental health counseling and help that they need. Explaining the problems are psychiatrist and author Jonathan Shay; Matthew Friedman, executive director of the VA's National Center for PTSD; VA psychiatrist Andrew Pomerantz; retired Navy psychologist Dennis Reeves; veterans' advocate and former Army Ranger Steve Robinson; Col. Thomas Burke, head of mental health policy for the Dept. of Defense; and Vietnam vet and VA counselor Jim Dooley. These excerpts are from their extended FRONTLINE interviews.

Psychiatrist and author, Odysseus in America

….I have to say that if you are a junior enlisted man or woman and feel that you are suffering from psychological distress, injury, dysfunction, whatever you want to call it, and the people around you know how to access it, and they're reachable as a practical thing -- you will get help. And that's a big change and an important change.

Now, as the mental health assessment team report, of which [Dr. Charles] Hoge's [Walter Reed] study was a part [See "Readings" section], found, the mental health resources weren't always physically accessible. People didn't always know where they were or how to get to them, that sometimes the local command was reluctant to release people from what they considered to be essential duties to get to them. So there were all kinds of barriers that don't add up to the problem of stigma.

However -- there's a big however here -- among staff non-commissioned officers, the sergeants, and among officers, there is the firmly entrenched belief that at least historically has been based on reality, that simply being known to have consulted mental health is career-ending. Now, there are people who pooh-pooh that and say 9/11 changed all that. Well, maybe it changed all that right inside the Pentagon, but there are plenty of things that happen right inside that Pentagon that never get out to the field in terms of actually influencing people's beliefs and behavior.

And my personal theory of what lay behind those horrible, horrible murder suicides at Fort Bragg a couple of years ago, these were all staff NCOs … and officers in Special Operations, which is the most macho of all the formations. And what's more, they had been deployed repeatedly into very dangerous, very confusing and ambiguous operations, and had come back with injuries that they could not ask for help with, because they were afraid it would end their careers. And just by coincidence, a number of them broke at the same time, and broke in this catastrophic way. That's my thought about what happened there. This is not likely to be happening with junior enlisted people who I think can get help.

… I think there's no substitute for people being able to number one, hear prestigious leaders talk about their own struggles with psychological injury. And the other thing is for them to see visibly that someone who has faced and gotten treatment for psychological injury continues to have a flourishing military career. I think the stigma is still a significant barrier in all of the military forces for officers and staff NCOs.

…The military career system for officers is a steeply-sloping pyramid. And people have to be promoted or they're out. There is built in there an incentive to make decisions based on what's going to be good for my career -- not the mission, not the welfare of the people I'm responsible for. The official ideology is the mission first, then people, and then me. That's the official ideology. The structure is to promote careerism. It's a structurally promoted careerism. And I've said to many military audiences, the biggest ethical problem in our forces today is not sexual lust, it's not financial greed, it's careerism.

The biggest role that careerism plays in mental health is not so much in seeking and getting help, although obviously, an officer who's afraid it's going to end his career is not going to go. But putting that obvious thing aside, the biggest thing about careerism is that it causes psychological injury in the troops. When an officer gets an irrational or unethical order or suggestion from his boss and goes ahead and passes that down and compels his subordinates to do something that is militarily crazy and dangerous to no purpose, just getting his people wasted because the boss wants it -- then this causes psychological injury in the troops who are faced with that situation.

… The troops are very much injured by the boss going astray and [thinking], "Oh, kill them all." The troops have a moral compass. And they are going to be injured by the boss losing his moral compass.

…I teach chaplains in both the Navy and the Army. And one of the things I point out to chaplains is that no commander has discredit reflected back on him when people [in his unit] go to the padre. In fact, it may even make the commander look good, which is one of the unique things about military chaplains, that they can deliver the goods where mental health people can't.

If a lot of people go on sick call for any reason, physical or mental -- unless of course it's because of enemy action -- it reflects discredit on command. So there's a disincentive to supporting that kind of self-care, by command. But if a lot of people go to the padre, what a great climate in that unit. Also, the chaplains have both de facto and de jure confidentiality that the military health people do not have. …

What about confidentiality? Is that an obstacle?

…The lack of confidence in confidentiality is a profound obstacle. Now, it's fair to say that there are conflicting goods here. … If someone is credibly threatening harm to others or to himself, it is your obligation to protect and to break confidentiality in the setting to the extent of protecting third parties and protecting the patient.

For a military commander to trust the mental health professional to get that right is a very hard thing for the commander to do, because he's afraid: "If this guy goes out of the shrink's office and takes his weapon and starts killing people, I'm the one who's going to have my neck in the block. And my bosses are going to say, how come you didn't take this guy's weapon away? How come you didn't get him out of the service, take him out of harm's way?"

So, those are conflicting goods. And I'm not ridiculing the commander there. They have real, big time responsibilities.

What is the confidentiality situation if a soldier goes to the VA for psychological, counseling services?

If an active duty soldier comes to the VA with the blessing of command, to my knowledge, they have exactly the same confidentiality protection, which is very considerable, of the ordinary VA patient. Now, if a soldier is required by his command to sign a release of information, then of course, it's all off. He's given permission to release the contents of the medical record. And I would hope that people aren't being coerced in that way.

Now, at a session in New Orleans at the trauma meetings -- the session that I ordinarily conduct every year -- I made the statement [that] there is no confidentiality of health records from command in the military health system. And heads nodded up and down around the room. These were all officers within the military health system.

And one person said, "Oh, no, no. I absolutely refuse to release any information if somebody comes to me." And so, I got a little debate going. And it turned out that this one contract military social worker felt that he was personally protecting the confidentiality of everyone in his setting. And I would say that to the best of my knowledge, there simply is no confidentiality of health records, including mental health records, from command, if command wants to know. Especially if you're an officer. Especially if you're an officer.

Exec. Dir. , VA National Center for Post-Traumatic Stress Disorder

…Would you talk about the stigma that exists in the military culture about seeking psychological counseling?

First of all, I'm a little uncomfortable with the way this has been playing out in the following way. It is not just the military culture where there's a stigma for mental illness. Mental illness is stigmatized throughout American culture. I think that the military context may magnify that, but I think it would be a mistake to believe that there's something fundamentally different about military culture and American culture.

Whereas the papers were full of Bill Clinton's need for cardiac bypass surgery, and there was no stigma that maybe some of the foods that he ate helped to clog his arteries, and there was no shame in having to require cardiac bypass or I dare say for any medical problem -- diabetes, you name it. It's talked about publicly, and people will talk in great detail about what medical or surgical procedures were necessary. Not so for depression. Not so for PTSD. Not so for anxiety disorders. Civilians who have these disorders, psychiatric problems, don't go public with them except on very rare occasions.

So I just want to emphasize that this is a cultural issue. I think in the military culture it becomes magnified because of the concern that a person who has PTSD or some other psychological problem can't be depended on, is going to be impaired, is going to jeopardize the unit. It also has to do with how military people feel about each other.

But in the military culture it is a problem. There obviously is a stigma.

Yes, I think stigma is a very big problem, and one of the most important findings that Dr. Charles Hoge and his colleagues at Walter Reed came up with in that New England Journal paper was not just acknowledging that there is stigma, but [quantifying] the magnitude of it.

We have known about stigma in the military for a long time. I was at a NATO meeting of mental health people about eight years ago in Ottawa, and we talked about this. But this is the first time, to my knowledge, that we've actually had numbers, we've actually been able to [quantify] the magnitude of this problem, and it is considerable.

What Hoge's data shows is that people who were most distressed psychologically, and in some cases so distressed that they had psychiatric problems that could be defined by very conservative criteria, number one, that they knew that they were distressed; they knew that they were functionally impaired as a result of their depression, PTSD or other anxiety disorders. So we're not talking -- and this is an important point -- we're not talking about people that may have had these problems but didn't know about it. They knew it. And these people who were most distressed were the ones who were most sensitive to the stigma. In other words, they were the ones who felt it was the most dangerous to come forward and seek help. And some of the reasons cited were they were afraid it would ruin their careers; they were afraid that their commanding officers would treat them differently; they were afraid that their colleagues, their peers would treat them differently. It was a shameful thing.

And what is stigma? It's about shame. So we have stigma in spades here. And I think Hoge's data does the military and military personnel a tremendous service by pointing out that this is out there, folks; this is a real problem, and we have well-trained men and women who could be treated because we have treatments that work in PTSD, depression. But they're not coming in for treatment because they're afraid to, so something's got to change.

Well, the only thing that can change is the health delivery system that can provide the help. And this is, I think, where the military is really struggling. One area where there's been a lot of interest is whether or not you can put the mental health treatment within a primary care treatment setting, which would, again, de-stigmatize to a great extent. I mean, the hope is that if people are coming to see their primary care doc rather than some psychologist or psychiatrist, that this isn't going to ruin their careers, and it won't be a cause for shame, etc. I think it's an interesting and important question.

We're working in a similar parallel system within [the] VA to integrate PTSD and mental health treatment within primary care settings. And I know Andy Pomerantz in White River Junction, Vt., has been a leader in that area. And we're actually hoping to launch some systemwide studies that may include military people. So I think that's one approach. I think there are other approaches that one might want to consider. ...

And again, a soldier who seems to be freaking out in a combat situation is viewed as a liability. And this is a perception, an attitude, that the military has to confront.

I say that it is an empirical question. That commanding officer is operating on an assumption, and the assumption is that whatever psychological distress, dysfunctional behavior that he's observing in his charge is irreversible, can't be changed, and that he's got to get the person shipped out because he doesn't want to endanger either the individual or he doesn't want to endanger the unit. And that is a belief that I think is very widespread.

I think the question is, is that a [legitimate] belief? And it becomes a very practical question when you consider the fact that tours are being extended in Iraq now because of the scarce manpower resources. If indeed there are treatments that are available that could quickly reverse this and could quickly enable people to resume their previous combat assignments, that would have an impact. This is a tough question, because we don't know, and that commander is saying, "Look, I can't take the risk." And I understand what he's concerned about. What we need is to find ways to demonstrate whether or not his concerns are legitimate or not.

My guess is that we'll be able to do that with the kind of data that Dr. Hoge and his colleagues have collected, because what we'll know -- and we won't probably know it before this war is over -- but what we will have information on is people who did have PTSD symptoms, who were sent back into the war zone, and then we'll be able to see whether or not they were able to perform. If they weren't able to perform, then the commanding officer is correct and they ought to be removed. My guess is, we're not going to find that for most of them. But that's the kind of information that needs to be produced, and I think until it can be produced, I have to be sympathetic with the concerns expressed by the commanding officer.

But I also have to be sympathetic to the people that are removed from the field of operations who feel after they've had some downtime or some treatment that they're ready to go back in. It's a serious question. There's all kinds of lives hanging in the balance. The answer needs to be thought through very carefully.

…How important is the issue of confidentiality in addressing the problem of stigma?

I think that you've put your finger on the major problem in the whole stigma issue, that if confidentiality could be safeguarded, if there could be a credible, feasible way that people could come forward and seek the help that they know that they need [but] without the risk that this information would be accessible, that would go a very, very long way towards solving this problem.

It's one of the reasons why I have some concerns about the integrated mental health primary care approach. On the one hand I think it will help a lot of people, but still, that's a medical record [that] is still going to be available, and how well the records can be safeguarded is an important question.

Chief of mental health services for the VA in Vermont

…Is there a stigma inside the military with regards to receiving mental health treatment?

The stigma to receiving mental health services inside the military and outside the military is huge. Many people simply either fear being exposed as a weakling, which certainly impacts on the military culture of strength, or actually fear retribution and punishment if they express psychological distress and suffering. We don't win wars by people having a hard time killing other people. We don't win wars by people suffering from nightmares and being overwhelmed by the stress of combat. Those don't win us wars. The military's purpose is to win wars. So someone who is suffering is not a big help to the military. And they know that, and you're surrounded by your buddies and "We're all in this together, and we're all going to fight to the bitter end -- who am I to say I don't think I can do this today?" ... That doesn't fit when everybody else is charged up to do what we're supposed to do. …

When soldiers come to you, is that meeting confidential? Is it in their records?

I don't know. This is something I'm looking at right now to find out the answer. The first time I saw an active-duty person it was actually just an Army recruiter. This was many years ago, and I was stunned when I got a request from his commanding officer to provide all the details, which of course I declined to do. And then [I] learned from the VA that they had a right to see those records, so I turned them over.

Since then, I'm very careful about what I write in anybody's record, and I think it's something that we all need to get better at. But since the [Health Insurance Portability and Accountability Act] regulations came into effect, I've lost a little bit of the clarity about that. I actually just sent a request to the privacy officer the other day to find out the answer to that question. Interestingly, she hasn't responded. We're still trying to figure out the privacy as we go along.

There's always a question: Who is my duty to? Within the VA, I have no question my primary duty is to the patient in front of me. There's no doubt in my mind about that. If they tell me something that they do not want in their record, it does not go in their record, period. If I was doing a disability exam, a forensic exam or something like that, I have to be very careful and very clear with the person in front of me to say: "I'm working for the VA. You know anything you tell me is going to go in the record." And knowing who you're working for is very important.

Is there more privacy for a vet who is not on active duty?

Probably. Probably, yeah. Medical records can be accessed by a lot of people. Now the VA has all computerized records and a lot of safeguards and a lot of tracking to see who has access to these records. It is as secure as any paper record system that I've ever seen. Information outside of an emergency can only be released to any other agency with the consent of the patient, who can then specify exactly what information is to go out.

What are the barriers in the military to seeking mental health treatment?

I think the biggest barrier that I hear about is being thought of as a wimp, someone who just can't hack it in the midst of a culture of people who can hack it. It's not till many years later that the veterans seem to be able to tell each other the stories of what it was really like for them, even to people that they went through the war with.

The second barrier probably is just the general stigma and the fear of retribution and punishment, that by coming forth with this information I am going to lose my position; I'm never going to get a promotion; I'm not going to be able to make the military my career the way I'd planned to; I'm just better off keeping my mouth shut. I think those are the big two.

And again, they're not specific to the military. It's everywhere. It's out there in the community, some communities more than others, some businesses and occupations more than others. But it's pervasive. …

Retired Navy psychologist

…How do officers react to the idea of their troops needing psychological help? Is there still a stigma?

Responses that I've received from commanding officers in terms of my interventions and my offer of support of their troops, both in Iraq as well as at home, have been quite wide-ranging. Some of them are very psychologically minded and do understand the effect of stress on an individual and are quite sympathetic. Those are easy. Other leaders believe that any mental health problem that an individual has is a sign of weakness.

So as a result, we have been able to start a pilot project that has been sanctioned by the highest level of Naval and Marine Corps medicine called OSCAR, which is [the Operational Stress Control and Readiness] project. And we have individuals in theater that are assigned to the battalions, and as a result, they train with them, and they become part of the family. Now, if you're in the family, you're frequently better accepted, and when the battalion surgeon talks to the commanding officer, he listens.

Now, when the battalion shrink talks to the commanding officer, he also knows that he can trust him and that he is not going to just try to let these guys use mental health as a ticket home, which is the major fear. And it's a legitimate fear, because if you allow two or three individuals to cry and convince you that they're not going to be able to cope and deal with the stress of deployment, [and] you let them go home, well, suddenly you're going to have an epidemic, and everybody's going to be lining up in mental health and trying to go home. Commanding officers know that. ...

Some love us, and some really would rather us not exist, especially when you're at war in the field. Commanding officers, their job is to maintain a fighting force. Military medicine's job is to maintain a fighting force. We both have the same job, but sometimes the approaches are different. …

Exec. Dir., National Gulf War Resource Center

…Is the stigma real?

It's absolutely real. The stigma is very real. It is almost a self-fulfilling prophecy that if a leader or a junior leader says, "I've got a problem," that when they come back you're going to look at them differently.

But there's enough evidence to show that if people get help early and often, they can recover and continue to fight. Now, whether or not we can convince the military of that and change the stigma within the military is a whole other question. But absolutely there's a big issue with stigma, and we have to rely on the medical health care professional to make the call.

One of the military guys said to us: "What do these mental guys know? Some of these combat stress control unit folks are young, inexperienced. They've never been in combat. What do they have to say to a commander?"

Well, he's right. He's absolutely right. What do they know? Have they ever been in war before? It's really a judgment call. It's a combination of what the clinician says and what you feel in your gut. And I'll tell you, when it comes down to war, and it comes to knowing for a fact that you can count on the guy to your left and to your right, if you have any doubt whatsoever, there's a problem in your team. If you've got any doubt whatsoever, you've got a problem. And it makes things even more difficult to know that you have to pay particular attention to Pvt. Joe because he went to mental health care while you're conducting your mission in Iraq.

Let me just say, you can't give up on your soldiers. And even some of the most powerful people in the world have sought and are seeking mental health care services. And you'd be surprised if we published a list of who takes Prozac -- the people that are on it, and how high-functioning they can be.

But on the other hand, it's a leadership decision. And these leaders that you talked to that said, "I don't want that guy back on my team," I can understand why they would say that, because you have to be on your game if you're going to survive. And if you're not on your game and you're lagging behind, or you can't process the orders that you're being given, you are a risk to everyone around you. And that is why it is imperative that when these people go to these combat stress teams that they get not a crystal-ball evaluation, but an actual evaluation about what their condition is and a medical determination so that the leader can be confident. "He's good to go, man. He is good to go. He's going to be OK, but keep an eye on him." …

A lot of the soldiers also say that they really won't trust anyone they're talking to in mental health because they know their command can get their hands on it. What are the confidentiality issues?

That's one of the reasons why I'm starting to question whether or not the military can actually make the soldier conform to the standards of the Uniform Code of Military Justice, deal with their mental illness, and maintain confidentiality and prevent stigma all at the same time. I don't think that if a military doctor meets a patient from this war and that patient says, "I want to kill people," or "I want to kill myself," that that should somehow be kept secret, like you're in a confessional. I think people need to know about that. In fact, the doctor has a duty to act. When somebody intimates a suicidal or homicidal ideation, they have a duty to act and talk to that person and really determine, "Do you mean that?," and if they do, to get them locked down or helped, whatever it is they need.

But for the command to get involved in -- other than [in] suicidal and homicidal ideation -- the confidentiality between the patient and the doctor is 100 percent inappropriate. And we do know that it happens. There's soldiers that have had their command try to influence the doctor's decision on whether or not somebody has PTSD or not, basically saying that they're faking it. …

Director of Mental Health Policy, U.S. Dept. of Defense

In the military, is there a stigma attached to seeking mental health care?

There is a stigma attached to having mental health problems and seeking help for mental health problems, but it's not limited to the military. It exists in our society as a whole. Now, the military culture is unique, and there is a certain perceived stigma, on the part of the soldiers, that they're not going to get promoted. They won't be trusted. Their buddies will make fun of them. They won't be a real man if they need mental health care.

We work very hard in the mental health community on educating the society as a whole [and] the soldiers themselves. The chain of command [is] that soldiers with mental health problems are not problem soldiers, they are soldiers with problems. And those problems have solutions. And for the vast majority of the soldiers, if they get help for those problems, if they take advantage of those solutions, they'll get better and go back to work. We need to continue to tell that message to the soldiers and to their chain of command, and we do that. …

What could the military do to remove the stigma attached to seeking mental health care?

One of the things that is unique about the military culture is that they give the Medal of Honor to the soldier who fights through pain and through being wounded and still completes the mission: takes the objective, takes the hill. We hold that up as an ideal, and that's appropriate that we should do that. But it's also true, although it doesn't make as good a story, that the soldier that takes good care of himself -- takes good care of his equipment, takes good care of his uniform, does the preventive things, stays healthy, keeps on doing his job, he's there day after day after day -- that soldier contributes as much as the Medal of Honor winner. But that kind of day-to-day heroism doesn't make the papers.

Mental health is part of that taking care of yourself. You know: good food, clean water, taking care of your uniform, taking care of your equipment, and making sure that you're getting enough sleep. And if that means that you have to go talk to the doctor, maybe find out why you're not sleeping at night, that's important. We try and educate people that that sort of day-to-day, simple thing is important. It doesn't mean that you're weak. It doesn't mean that your buddies can't depend on you. It means that you're taking care of yourself properly so your buddies can depend on you.

Is there the perception that if you seek care you are weak?

I agree that there's a perception, on the part of the soldiers, that if they seek mental health care, if they express emotion, that they're going to be perceived as weak, or as a failure, or that they're not going to be reliable, that they can't do their job. I don't think that that perception is the truth. I agree that the culture may have been that way in the past, may be that way, to some degree, now. I don't think that it needs to be that way in the future for the military to effectively do its job.

But is there the possibility that if someone in a leadership position owns up to experiencing these kinds of mental health issues, he will be removed of his command?

… It's a hard question to answer. With a sergeant, [or] someone who is in a leadership position develop[s] symptoms like you're talking about, there's always a question of: Is this a character issue? Is it a behavioral issue? Is it an issue of motivation? [Is this] something that leadership can handle, or is this a medical issue that you can put some kind of medical label on and treat it through medical channels? That's a hard thing to sort out.

… But that's what the chain of command has to deal with, and they have to make those decisions as to whether or not a person can stay in a leadership position [and] continue to do the job that they do based on all of these factors. …

Is it difficult for soldiers to talk to each other about their feelings?

I think that, yes, it is difficult for soldiers, especially young guys, to talk about their feelings, even when they're outside of combat. Whenever they're in combat, this unusual experience has happened to them, and they may feel that their careers are on the line, maybe their very lives are on their line. It's difficult to be able to express those feelings. They may not have the vocabulary for it. They may not even realize what it is that they're feeling. It comes out in odd ways sometimes, like kind of weird humor. … Sometimes that gallows humor is the way that Marines and soldiers choose to express their anxieties or their concerns about what they've seen and what they've done.

If we can get them in to talk to us -- providing them with vocabulary, providing them with a little bit of insight and with some reassurance that what they're feeling is what everybody else is feeling, that it's normal to feel those things -- that may help them to deal with those [emotions] and to not be so distressed about the experience of having those emotions. But again, it's a matter of getting them to come in and talk to us a few times so that we can give them that education, those skills, that reassurance.

So it is difficult for them to come to you and talk to their friends, their superiors, about these feelings?

You're absolutely right. It can very difficult for them. But just because it's difficult doesn't mean it's not important and doesn't mean that they shouldn't try and do it.

If they come and talk to us -- military psychiatrists, psychologists, people with experience, people who have been around the military -- we know ways to provide a safe environment for them to talk about this, provide them with some vocabulary so that they can talk about it in ways that … are going to be socially acceptable to them. But we have to get them to come in and talk to us. I would encourage them to do that.

…The mental health care system is often the last person that the soldier will talk to. They'll talk to their buddies first. They'll talk to the first Sergeant. They'll talk to their squad leader. They'll talk to others in their chain of command. They'll talk to the chaplain. The chaplains are very, very important in getting the soldiers the kind of care that they need because they can be a kind of conduit. They can get a pretty good feel for what just needs a little bit of talk and what needs more intensive counseling or medication …

What can be done to remove the stigma attached to seeking mental health care, to prevent these kinds of tragedies in the future?]

There's a stigma with getting your arm fixed or your leg fixed. I went to airborne school long, long ago, and they made us run down the ramp and had the instructors watch. And they were watching for people with limps because people would hide broken legs because they didn't want to wash out of the course.

…This issue of the stigma of mental health is not isolated to mental health, it's not isolated to the military.

Do I believe that I can convince every single sergeant, every single officer in the Army and the Marine corps that it's okay for soldiers to talk about their emotions? No. It'll never happen. But can I make a difference? Do I believe that I can make a difference? Do I believe that the mental health system, by continuously trying to educate, trying to elevate awareness, trying to do a good job, send soldiers back to work, provide effective care, that we can make it better? Absolutely, I believe that. And that's why I'm here talking to you.

Mental health counselor, U.S. Department of Veterans Affairs

…The Army now does offer combat stress control [to] people who are actually in combat: trained therapists, counselors, psychologists, even psychiatrists. [But the anecdotal evidence] is that [for] soldiers who actually seek help, the stigma is so huge, most won't seek help in the field, in combat, in theater. And if they do seek help, the stigma that happens to them and their careers afterwards is so detrimental that it just sets an example for all the other folks who might use [the resources].

Talk to me about just the military culture and how that actually … [affects] getting the help that you might need in theater.

The military career is based upon being powerful and being in command at all times. I have a picture of John Wayne on my wall, because we as men are taught to be John Wayne from about 2 years old onward by our mothers. I think that's really cool, and yet the problem with attempting to be John Wayne is that you can't be yourself. You can't be expressive; you can't have weaknesses; you can't have reactions; you can't have sadness; you can't be grieving; you can't be confused, lost.

When you look at soldiers in the command structure, how people make advancement is on their fitness for duty, their readiness, their ability, their successes. If a person is struggling, that's not necessarily good for their career. I've had soldiers come in quietly, not wanting the military to know, asking me directly, "Does the military have access to my records here?" So there is a significant concern that they will not be made for the next promotion. They will not get that next job based upon the perception that we have a weak link.

Is it a realistic fear that if they do turn to mental health professionals, ... their careers [may] be affected detrimentally?

I think that it's a very gray area, because the soldier is not necessarily an employee that can say to their employer: "I have a right to privacy. You can't see my records." A soldier is part owned by the military. If you hurt yourself in the military, they can charge you with destruction of government property. I love that one. So at some point, the military can require that you provide those records, if they know about them. And that becomes a dual-edged sword. So I think there's a real disincentive for coming in for counseling and to admit that you have a mental health issue to begin with. Even in American society in general, it is the most discriminated[-against] disability that there is.

A soldier comes to see you. You're part of the VA. Are his records confidential?

His records are confidential as long as he's not required to sign a release of information for the military to access it. If the military says to him, "We require to see your records at the VA," then the soldier has a problem.

Can the military do that to any soldier they want to?

You betcha. The military, I believe, can request fitness-for-duty reports. If they have questions about a soldier's ability to function, they have a right and a responsibility to make sure about that. So there is a conflict of interest, let's say, between fitness for duty and the right for privacy. And in the scheme of things, the government says, "Our right supersedes your right for privacy, and if you're not willing to allow us to see those records, then we're going to make decisions based upon that."

It seems pretty obvious then, why soldiers don't seek out help for their mental health issues.

The issue of talking to somebody when you're having problems I think really is a major problem. I think we don't do any kind of real assessment of after-action. We don't do debriefing. The best case is that if the unit is pulled off the line for resting time, alcohol will be available, and you and your squad of eight men can all get drunk and be stupid and sloppy and talk to each other and reveal. And that's probably as close to what will be expected, permitted, structured as the military will provide. I think that to do otherwise would be to really invest heavily in this area. They have MASH units that are fully equipped to deal with blood; the military, I think, avoids emotional blood. I don't think they see it as real problems. And I think that's the problem. …

…When I was in Vietnam, there was a man walking point before me by the name of Schwartz, and Schwartz lasted three days walking in minefields. And on the fourth day we said, "Saddle up," and he just started crying. He said, "I can't do this anymore." The commanders made him into a cook at base camp. I thought that was a humane treatment of a man that really, really tried.

We have to look around at what ... it means to have a reaction to trauma, to seeing a dismembered body and internalizing that: It could be me, I could be next, or maybe I'll do that to somebody. At some point, we can't make those kind of judgments for somebody else's view. And I think that we need to be open to allowing the soldiers to be human and not to be a machine, because when they become a machine, they're not human anymore. That's part of the problem.

Your command made the guy a cook, but that's not what I'm hearing happens in most cases. Tell me what really happens.

What really happens is that the command looks around and says, "If we let this guy loose, we're going to have a herd going in the same direction, and therefore we're going to have to set real limits." And they set limits that are really not respectful. It's a trap. Once you're in, you're in, and no amount of whining will get you out. Yet that doesn't really address the issue of real people struggling and emotionally bleeding and not being able to function. …

What I'm seeing is they actually do have these guys in the field -- They have some of these [counseling] guys out there --

If you look carefully -- you've got to get past the PR stuff -- they have privates; they have corporals; they have ordinary soldiers walking around different units saying: "How ya doin'? What's news?" And that's what they have. If you really look around at the company that [is] doing the assessment, there is [one] psychologist. There is not a company of psychologists. That's a different price tag. That's a different level of professionalism of real understanding of assessment. They don't have transportation proper. They don't have communication.

At some point, it's a PR piece, in my opinion. If they wanted to provide a company of psychologists to do the assessment and to do the triage and to do the PTSD assessments, that would really help them to retain more people and to recover people that are troubled back into active-duty service again. But at some point they see it as a threat, a very clear threat to them, and they don't --

What's the threat?

The threat is that they'll lose control of who goes and who stays, that the psychologists will then become the ultimate decider. And I don't think that they like that, because there's a disregard for psychological babble talk. It's easy to quantify a bullet wound or a blast and an amputation into money. It's much more difficult to say, "I have these problems, and I can't function because of these problems that are in my head." That's a harder place for the military to trust that it would be fair. …

While in the military or in the VA, have you seen evidence that if people were to ask for psychological questioning it is, in effect, the end of their career?

I've seen that people seeking counseling have been reassigned, and their job has been taken away from them because of that. It can be because of the command decision to reduce the stress, or it can be the command decision that the person is in a job that needs to have somebody fully functioning. And I'm not making a judgment of how they do that, but [it does] have an impact on their career[s]. …

The issue of the military having a reaction to a person's seeking help really comes down to the perception that seeking help means that they have a weakness of character and that can they [n]ever be trusted again not to break. Therefore, [the military] opts not to take the risk, as opposed to invest[ing] in the person. There's a real difference if you consider the resource of the person or [if] you consider the person a unit. And if that unit has a history of seeking counseling, what will happen in the future? The [answer] is, we pass on that person. It's the avoidance of risk with no justification for why they're doing it.

So, the second that you have an issue or a problem or have an adverse reaction to something horrible that you just saw, you're just sort of kicked out? What's that about?

It has to do with the unrealistic expectation that you can take anything -- anything -- and not break. We are deluding ourselves on that issue. We all have breaking points. All you need to do is be presented with it, and you'll break. Will you break in the future? Not necessarily. But then again, maybe yes.

That's really what it's about. We assume that the military is omnipotent and ever strong and made of steel. [But] it's struggling human beings. That's what it's about. …